预致敏受者行死亡捐献供肾肾移植的处理策略及临床效果

Strategy and clinical outcome of deceased donor kidney transplantation for presensitized recipients

目的探讨供肾来源于死亡捐献供体的情况下,预致敏受者行肾移植的处理策略和临床效果。方法回顾性分析华中科技大学同济医学院附属同济医院2011年1月至2018年6月施行预致敏受者接受尸体供肾再次移植21例的临床资料,包括13例群体反应性抗体(PRA)阳性而供者特异性抗体(DSA)阴性受者及8例预存DSA阳性受者。观察移植肾早期恢复情况、急性排斥反应(AR)发生率、DSA变化、移植肾和移植受者存活率。结果21例受者均无移植肾原发性无功能和功能恢复延迟。13例PRA^+/DSA^-受者中4例发生5次细胞性排斥反应(CMR),8例预存DSA+受者中5例AR,其中单纯CMR 3例,混合性排斥2例。所有AR均治疗后成功逆转。预存DSA^+受者在肾移植后,4例DR-DSA或Ⅰ类DSA均转阴,5例DQ-DSA有4例保持阳性。中位随访26个月,所有受者的移植肾功能保持正常,移植物及受者存活率均为100%。结论死亡捐献时代下,积极的配型筛选及供肾质量筛选,结合一定的围手术期处理,能使困难预致敏受者获得肾移植机会并取得满意疗效。

Objective To explore the management strategy and clinical outcome of renal transplantation in presensitized recipients using deceased donor kidneys.Methods From January 2011 to June 2018,twenty-one presensitized patients,including 8 with positive donor specific antibodies (DSA) and 13 with positive panel-reactive antibodies (PRA) but no DSA,received renal retransplantation from deceased donors in our center.The incidence of delayed graft function (DGF) and acute rejection (AR),changes of DSA,and the graft and patient survival were retrospectively analyzed.Results None of the renal allografts had primary non-function (PNF) and DGF after transplantation.Four of the 13 recipients with PRA^+/DSA^-had a total of 5 episodes of acute cell-mediated rejection (CMR),while 5 of 8 recipients with pre-existing DSA^+ developed AR,including 3 cases with CMR alone and 2 cases with mixed AR.All episodes of rejection were successfully reversed after targeted treatment.Interestingly,of the 8 recipients with positive preformed DSA,4 cases with positive DR-DSA and/or class Ⅰ-DSA had their DSA disappeared after transplantation,whereas DQ-DSA remained positive in 4 of 5 recipients.After a median follow-up of 26 months,all recipients maintained normal renal allograft function,and the survival rates of both graft and recipient were 100%.Conclusions With the use of deceased donors,kidney transplantation can be successfully performed in presensitized patients by appropriate HLA-matching screening,choosing donor kidneys with good quality,and the combination of optimal perioperative treatment.